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Abstract |
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• Objectives To pilot test an intensive care unit–based nursing screening intervention to assist in determining the discharge needs and outcomes of critically ill elderly patients.
• Method A randomized clinical trial with in-hospital and mailed questionnaires was used. Patients 65 years and older who were hospitalized in 1 of 2 intensive care units at 2 midwestern university-affiliated medical centers were recruited for the study. Control patients (n = 53) received usual discharge planning; experimental patients (n = 47) were screened in the intensive care unit by using the Discharge Planning Questionnaire. Both groups were assessed for readiness for discharge when discharged from the hospital and were followed up 2 weeks later with a survey completed at home.
• Results One hundred patients 65 to 90 years old (mean 73, SD 5.78) completed the study. Sixty-six percent were men. The 2 groups did not differ with regard to age, race, sex, severity of illness, lengths of stay in the intensive care unit or hospital, education level, or income. Patients in the experimental group were more ready than patients in the control group for discharge (P = .06). Patients in the experimental group were also more likely to report they had adequate information, had less concern about managing their care at home, knew their medicines, and knew danger signals indicating potential complications.
• Conclusion Intensive care unit–based early discharge planning can affect elderly patients’ preparation for discharge.
Discharge planning for hospitalized elderly patients is essential to the patients’ ability to continue recuperation and return to premorbid functioning.4 Research on patients’ perceptions of satisfaction with hospital care in a US survey5 of 6455 adult patients after discharge revealed that problems with discharge preparation were most prevalent among patients 66 years and older. Specific problems mentioned by all patients included not being told about (1) the purposes and side effects of medications; (2) restrictions in activity, work, and foods; (3) danger signals to watch for at home; and (4) what to do to help recovery.6
| Comprehensive discharge planning protocols decrease readmissions and costs for hospitalized elderly patients.
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Several studies indicated the benefit of discharge planning for elderly patients. A series of studies7–10 established that for hospitalized elders, use of comprehensive discharge planning protocols and follow-up by advanced practice nurses resulted in decreases in hospital readmissions and in the costs of providing healthcare. Other studies11–13 indicated that use of a geriatric multidisciplinary team, case managers, and liaison nurses reduced the number of hospital readmissions, improved patients’ quality of life, and increased the quality of the discharge planning.
Although implementation of case management and critical pathways in the intensive care unit (ICU) has focused attention on facilitating cost-effective, coordinated care, discharge planning is not a consistent component of case management in acute care nursing.14,15 Discharge planning in the ICU has been nonexistent, or unstructured, because traditional discharge planning for critically ill patients has been addressed after transfer from the ICU.16 Beginning to anticipate discharge needs while patients are in the ICU would provide additional time for planning for home care needs and subsequently prevent delays in discharge. This additional time becomes especially important for elderly patients because early discharge planning has been linked to their ability to continue recuperating and return to premorbid functioning.16
The purpose of the study reported here was to pilot test an ICU-based nursing screening intervention to assist in determining the discharge needs and outcomes of critically ill elderly patients.
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Method |
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TopAbstractMethodResultsDiscussionReferences |
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Sample
Patients 65 years and older who were admitted consecutively to 2 ICUs at 2 midwestern university-affiliated medical centers were recruited for the study. Of 263 patients, 77 (29%) were not eligible, and 52 (20%) refused to participate in the study. Of the 134 patients enrolled, 7 (5%) withdrew, 7 (5%) died, and 20 (15%) did not return the 2 week follow-up survey. A total of 100 patients completed the study. The period of enrollment was 12 months in order to obtain the required sample size as originally determined by power analysis.
Instruments
The Discharge Planning Questionnaire (DPQ)17 was used to assess discharge needs. The DPQ is a 51-item questionnaire that is used to assess patients’ perceptions of anticipated needs after hospitalization. High scores on the DPQ suggest greater limitations and potential need for assistance and/or education for managing care after discharge from the hospital. Categories assessed include activities of daily living (ADL), instrumental activities of daily living (IADL), environment, social support, and patients’ preferences for discharge arrangements. Scale steps are sequenced so that a higher number suggests greater risk or need for follow-up care.
The Cronbach 
for internal consistency reliability was .90 for the ADL subscale, .87 for the social support subscale, and .60 for the environment sub-scale.17 Content validity of the DPQ was supported by an index of content validity of .92. Concurrent validity was established by using the performance ADL sub-scale; the reliability coefficient was 0.93.17 The DPQ also had predictive validity; scores correlated with the total number of community resources used after discharge (r = 0.65).
For the study reported here, the Cronbach for internal consistency reliability was .95 for the IADL subscale, .91 for the ADL subscale, .96 for the social support subscale, and .94 for the environment subscale.
The Acute Physiology and Chronic Health Evaluation III (APACHE III) was used to assess illness severity. Scores on the APACHE III are based on the values of 16 routine physiological measurements (heart rate; mean arterial blood pressure; temperature; respiratory rate; hematocrit; white blood cell count; serum levels of creatinine, urea nitrogen, sodium, albumin, bilirubin, and glucose; arterial blood gas data; and 24-hour urine output), comorbid conditions that influence a patient’s immunological status (hepatic failure, lymphoma, metastatic cancer, acquired immunodeficiency syndrome), and age.18 The scores (range 0–299) provide a general measure of the severity of disease. A 5-point increase in score is associated with a statistically significant increase in the relative risk of dying while in the hospital.18
Support for validity was provided by Knaus et al,19 who found that 95% of 17 440 patients admitted to ICUs in 40 US hospitals could be given a risk estimate for death during the patients’ stay in the hospital that was within 3% of the actual percentage of patients who died. The APACHE III scores accounted for a substantial proportion of the variation in death rates (R2 = 0.90) even when the observed rates of deaths in the hospital varied from 6% to 42%.
For each patient, the adequacy of discharge planning was assessed 2 weeks after the patient’s discharge from the hospital by using the Discharge Adequacy Rating Form. The form consists of 14 questions and is used to assess the type of discharge planning and home instructions given to patients before discharge from the hospital.
The transition and continuity items of the Picker/Commonwealth Patient Interview Questionnaire20 were used to assess adequacy of discharge planning from the patients’ point of view. The Picker/Commonwealth Patient Interview Questionnaire is used to assess components of patient-centered care. The development of the interview questionnaire for a national survey of 6455 adult patients on aspects of hospital care established face and content validity.5,6 Because it is a survey instrument, reliability estimates cannot be calculated; however, components of the instrument were used with favorable results in a large-scale research study of 4600 adult medical-surgical patients.21 For this study, 4 additional questions to assess patients’ perceptions of discharge readiness, when information about discharge was given to each patient, and additional information that would have been helpful were included.
The SF-36 was used to assess functional and health outcomes at 2 weeks after discharge. This instrument consists of 36 items in 8 subscales and is used to measure 3 major concepts of health status: overall evaluation of health (general health), functional status (physical functioning, social functioning, role limitations attributed to emotional problems, and bodily pain) and well-being (mental health and energy or fatigue). Higher scores on the SF-36 indicate a better health state.22,23 Scores on the subscales are transformed to have a consistent range from 0 to 100 to enable comparisons with national norms.
Test-retest and internal consistency methods indicated the reliability of the SF-36 across a variety of diverse groups of patients, including populations in the United States and the United Kingdom.23 Construct and criterion validity were also supported for patients with and without chronic conditions. Additional factor analysis demonstrated a 2-factor (physical and mental) model of health across populations.23 The physical component summary consists of the physical functioning, role-physical, bodily pain, and general health subscales. The mental health component summary consists of the vitality, social functioning, role-emotional, and mental health subscales.23
A chart review form was developed to collect information related to length of stay; diagnoses; ICU treatments received, including oxygen therapy, mechanical ventilation, invasive monitoring, blood products, and other invasive/therapeutic treatments; and documented discharge planning. The form was completed by a research nurse during a retrospective chart review.
Procedure
Criteria for inclusion in the study were (1) hospitalization in an ICU for a minimum of 24 hours, (2) age 65 years or older, (3) ability to give informed consent, (4) ability to read and speak English, and (5) a mailing address. After the study was approved by the institutional review boards of the participating institutions, nurse research assistants approached patients in the ICU to enlist the patients’ participation in the study. The assistants used a standardized script that included a description of the study, and informed consent was then obtained. A table of random numbers was used to randomly assign patients to 1 of 2 groups. The experimental group received screening with the DPQ within 24 to 48 hours of admission to the ICU. The control group received general discharge planning (no ICU intervention screening).
For each patient, the results of the DPQ screening were communicated to the discharge planning nurse when the patient was transferred from the ICU. This step represented a formal structured communication of the results of the ICU screening to the discharge planning nurse and allowed initial determination of which patients might need formal discharge planning. Patients in the control group received general discharge planning (no ICU intervention screening). At both data collection sites, discharge planning was unstructured; discharge planning nurses did routine screening of each patient 1 to 3 days before the patient’s discharge or on the basis of a specific referral by a physician, nurse, or social worker.
Patients were followed up daily to assess the possibility of discharge. In addition, on the day before his or her anticipated discharge from the hospital, each patient was interviewed by a nurse research assistant to assess the patient’s perceptions of readiness for discharge, concerns about going home, and information related to when the patient had received discharge instructions. Two weeks after discharge, each patient was mailed a survey to assess functional status (SF-36), health status (Perception of Health Status rating), and perception of adequacy of discharge planning.
In addition, a subset of patients from both groups (n = 41) was contacted by telephone 48 hours after discharge from the hospital to determine immediate needs after discharge that were not being detected in the survey done 2 weeks after discharge. The telephone follow-up was used to assess patients’ current activity status, general state of health, and any current concerns or problems after discharge.
Data Analysis
Descriptive statistics were used to assess group characteristics. Differences between the 2 groups in demographic and illness-related variables were determined by using t tests and 
2 tests. Means and SDs for subscale scores for the DPQ were used to describe the discharge planning scores of patients in the experimental group. Differences between the 2 groups in perceptions of readiness for discharge were determined by using t tests and 2 tests. Analysis of covariance was used to examine the effect of DPQ screening (independent variable) on length of stay and discharge readiness ratings (dependent variables), controlling for severity of illness as measured by APACHE III scores. Differences between the 2 groups in documented discharge planning were assessed by using 2 tests.
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Results |
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). The 2 groups also did not differ significantly in ICU length of stay, hospital length of stay, APACHE III scores, diagnostic categories, or ICU treatments received (Table 2). The mean lengths of stay were 10 days (SD 7) in the hospital and 4 days (SD 4) in the ICU. APACHE III scores ranged from 23 to 93 (mean 50, SD 15). Most of the patients were admitted because of cardiovascular, peripheral vascular, oncological, hepatic, or gastrointestinal disorders.
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). At 2 weeks after discharge, the SF-36 general health and role-emotional subscales were significantly higher in the experimental group than in the control group (Table 4), indicating better health in these areas.
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Patients whose discharge planners used the DPQ information differed significantly from patients whose discharge planners did not. Patients whose discharge planners had used the DPQ information were more ready for discharge (mean score 9.2 on a 10-point scale, compared with 8.2, P = .06; Table 5) and had less concern about managing their care at home (mean score 1.8 on a 10-point scale, compared with 2.9, P = .09). These patients also had higher DPQ environment, social support, ADL, and IADL scores (P <.001), suggesting greater limitations. These patients were also more likely to have a shorter ICU length of stay (mean 2.3 days, compared with 3.4 days, P = .02) and shorter hospitalization stays (mean 8.4 days, compared with 10.0 days, P = .08), but not higher APACHE III scores (P = .41).
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Telephone Follow-up
A subset of patients from both groups (n = 41) was contacted by telephone at 48 hours to assess immediate needs and concerns after discharge. Of these, 20 patients were in the experimental group and 21 were in the control group. The telephone follow-up was used to assess each patient’s current activity status, general state of health, and any current concerns or problems. Of the 41 patients contacted, 12 (29%) required specific health maintenance information or instructions. The patients sought advice about reporting symptoms such as shortness of breath, pain, and wound drainage; verifying medications; scheduling follow-up appointments; and obtaining home equipment (Table 6).
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| In 29% of cases, telephone follow-up at 48 hours resulted in nursing actions.
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Compared with the other patients contacted by telephone, the 12 patients who needed assistance were more likely to have had coronary artery bypass graft (CABG) surgery (2 = 7.08, df = 1, P = .01), were older (mean age 75 years vs 72 years for the patients who did not need assistance; P = .53), had higher APACHE III scores (mean 56 vs 52, P = .67), and had longer stays in the hospital (mean 10.8 days vs 9.3 days, P = .85). In addition, fewer of the patients who required assistance reported that they were ready for discharge (60% vs 69%, P =.48). The patients who required assistance also were more likely to report that they did not know their medicines well (17% vs 7%. P = .40), did not know the side effects of their medications (50% vs 34%, P = .63), and did not know the danger signals indicating potential complications (50% vs 34%, P =.33).
In the total study sample of 100 patients, 27% had undergone CABG surgery. Compared with patients who did not have CABG surgery, patients who had the surgery were more likely to report that they were not ready for discharge (38% vs 32% of patients who did not have CABG surgery; P = .50), did not know their medicines well (50% vs 31%, P =.22), did not know the purposes of their medicines (38% vs 28%, P = .55), and did not know the side effects of their medications (54% vs 42%, P =.57).
Discharge Planning Readiness
The majority of patients in both the experimental (68%) and control (62%) groups reported that information about plans for discharge was communicated on the day before or the day of discharge. The majority (68% and 70%, respectively) also reported that discharge instructions were given on the day of discharge. Patients in the experimental group were more ready than patients in the control group for discharge (P = .06).
A total of 97% of patients in the experimental group and 98% of patients in the control group had documented discharge planning. The 2 groups did not differ in the type of discharge documentation about home care needs, social or family situation, referrals, or placement. For both groups, most of the discharge documentation was recorded by a nurse in the unit (62% for the experimental group vs 56% for the control group) or by the discharge planner (72% vs 64%, respectively).
Of the 47 patients in the experimental group, 22 had high DPQ environment scores (Table 7), 33 had high DPQ social support scores, 13 had high DPQ ADL scores, and 27 had high DPQ IADL scores, suggesting greater limitations. DPQ social support scores were higher for men than for women (2 = 7.2, P = .01) and higher for married patients than for unmarried patients (2 = 19.4, P < .001). Compared with patients with lower DPQ environment scores, more patients with high environment scores reported that they received discharge instructions on the day before or the day of discharge (2 = 10.85, P = .05). The patients with lower scores reported that they received discharge instructions up to 3 or more days before discharge.
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2=12.8, P =.002). Five patients had high scores for all DPQ subscales and differed from those with lower scores in age and in functional status 2 weeks after hospitalization. The patients with higher scores were older (mean age 78 years vs 73 years, t = 1.9, P = .05) and had lower SF-36 subscale scores in vitality (mean score 24 vs 40, t =–1.9, P = .05) and mental health (mean score 53 vs 77, t = –3.4, P = .001).
Of the 47 patients who received the early discharge planning, 13 lived alone and 27 lived with a spouse. The patients who lived alone and those who lived with a spouse did not differ in age, APACHE III scores, or hospital and ICU lengths of stay.
Comments obtained from patients on the day of discharge related to concerns about getting their strength up, pain management, and managing care at home. Several comments pertained directly to discharge planning. One patient commented, "I should have been given more notice about discharge and started teaching earlier." Another related, "I didn’t know how I’d manage with such short notice—dressing changes and infections—as teaching just started the evening before discharge."
Comments from patients 2 days after discharge indicated that some patients felt stronger and were having decreasing pain, but others had continued weakness, needed assistance with ADL, and had continuing signs and symptoms such as shortness of breath and wound drainage. One subject related, "I am doing better but still having some difficulty breathing." Another stated, "It was a surprise to be leaving the hospital when I did. The doctors told me at 5:30 in the evening to have my family at the hospital at 9:30 the next morning to learn my home instructions. I was on my way at 9:30 AM. Under the circumstances, I am doing well—without my family, I wouldn’t be able to do anything."
At 2 weeks after discharge, patients were asked what could have been done to help prepare them better for managing their care at home. Specific comments included "a follow-up call from the doctor within 48 hours would have been nice," "information about what to look for in terms of side effects," "better instruction on how to use/reduce my oxygen," "more specific information—nothing was said about exercise or walking," and "I was not at all prepared to know what danger signals about illness to watch after going home."
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Discussion |
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A limitation of the study was that use of the DPQ screening information by the discharge planning nurses was optional. Of the 7 discharge planners, 3 reported using the screening tool information consistently to determine potential discharge needs. Discharge planning nurses who did not consistently use the information reported that the form was too long and did not provide much supplemental information over the information obtained via their interviews with patients. Because patients reported a benefit if their discharge planner used the screening results, additional study of the use of early discharge screening for elderly ICU patients is needed.
Telephone follow-up within 48 hours after discharge from the hospital did reveal health education and health maintenance needs after discharge. Of the 41 patients who received follow-up telephone calls, 12 (29%) required a nursing intervention. The most common intervention involved answering questions about infection, pain, and medications. The concerns were serious enough that in 11 instances, the patient was instructed to notify his or her physician and in 1 instance, the patient was advised to go to the emergency room.
Similarly, Bostrom et al24 found that telephone follow-up of 414 patients at 2 to 3 days after discharge revealed inadequate knowledge of discharge care. Patients expressed concern about how to recognize a complication and about activity level, diet, pain management, rest, and follow-up appointments. Bostrom et al concluded that patients may not have understood discharge instructions and that standard discharge instructions should be more comprehensive in terms of ADL.
In this study, subjects who required telephone assistance were older, had undergone CABG surgery, had higher APACHE III scores, and had longer lengths of hospitalization than did patients who did not require telephone assistance. In addition, fewer subjects who required telephone assistance reported that they were ready for discharge, and they were more likely to report that they did not know their medicines well, did not know the side effects of their medications, and did not know the danger signals indicating potential complications.
Adequate knowledge of discharge care is especially important for acutely ill elderly patients. In a study of the perceptions of acutely ill elderly patients of an ideal approach to discharge planning, Wells et al25 identified several critical elements, including oversight of the discharge plan and involvement of the patient and his or her family members. Follow-up after discharge, such as a telephone call, may result in improved knowledge for patients, early detection of complications, and fewer hospital readmissions. However, further research is indicated.
Early discharge planning for hospitalized elderly patients is essential to their ability to continue recuperation and return to premorbid functioning.14 Research on patients’ perceptions of satisfaction with hospital care from a nationwide survey of 6455 adult patients after discharge from the hospital5,6 revealed that problems with discharge preparation were most prevalent among patients 66 years and older. Specific problems identified by all patients included not being told about the purpose and side effects of medications; restrictions in activity, work, and food; danger signals to watch for at home; and what to do to help recovery.20
| Two weeks after discharge, one third or more of patients did not know the purposes or side effects of their medications or danger signs for possible complications.
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Similarly, in this study, at 2 weeks after discharge, 31% of the patients reported that they did not know the purpose of their medicines, 46% reported they did not know the side effects of their medications, and 35% reported they did not know danger signs indicating potential complications.
Although efforts to increase patients’ knowledge of medications, activity, and follow-up care have been studied, a more comprehensive approach to discharge preparation may be needed. McPhee et al26 examined the effectiveness of a structured discharge interview for 545 hospitalized patients. The interview consisted of a 15-minute instructional session that included a written outline and explanation of the patient’s diagnoses, medication (including name, purpose, dose, route, schedule, and common side effects), diet, activity, and follow-up care. At 1 month after discharge, the patients who had the interview did not differ in knowledge, compliance, and functional status after hospitalization from patients who did not have such an interview. McPhee et al concluded that effective education of patients may require more than simple one-time verbal or written instructions.
Although the goal of discharge planning is to start the discharge planning process at admission, most of the subjects in this study reported that preparation for discharge was done on the day before or the day of discharge. Timely and targeted use of discharge preparation and hospital support services for acutely ill elderly patients could result in better outcomes by preventing complications after discharge and rehospitalizations, yet further study is warranted.
A priority for future research should be continued study of strategies to improve the transitional care outcomes of older adults.27 A recent systematic review28 of discharge planning from hospital to home revealed that only 8 clinical trials have been conducted in which discharge planning was compared with routine discharge. Of those 8, only 3 were focused on elderly patients. As a result, evidence about the impact of discharge planning on costs and patients’ outcomes for hospitalized elderly patients is inconclusive. Additional research is needed on the effect of ICU-based discharge screening and home follow-up interventions for acutely ill elderly patients.
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ACKNOWLEDGMENTS |
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REFERENCES |
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